Terrace View Long Term Care Facility

Deficiency Details, Certification Survey, January 20, 2012

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.
(a) Infection Control Program
The facility must establish an Infection Control Program under which it -
(1) Investigates, controls, and prevents infections in the facility;
(2) Decides what procedures, such as isolation, should be applied to an individual resident; and
(3) Maintains a record of incidents and corrective actions related to infections.
(b) Preventing Spread of Infection
(1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.
(2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.
(3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
(c) Linens
Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED 1/29/10 and 12/10/10.

Based on observation, record review and staff interview, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Seven (Residents #230, 245, 282, 309, 469, 505, 605) of seven residents reviewed for infection control practices had issues with improper hand hygiene while providing meal assistance, use of improper bathing techniques and improper handling of soiled linens. All issues occurred at the Erie County Home. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Resident #230 has diagnoses including cerebral vascular accident (CVA -stroke). Review of the Minimum Data Set (MDS) dated 12/1/11 revealed the resident is cognitively intact. Review of the current ADL Plan of Care printed 1/4/12 revealed the resident requires set up help for meals.

During an observation of dining on Unit K on 1/12/12 at 12:04 PM, certified nurse aide (CNA) #1 removed plastic wrap from a sandwich, applied mustard to the sandwich then held the sandwich down with her left hand while she cut the sandwich in half using her right hand. The CNA did not use a barrier between her hands and the resident's food. The resident was observed to eat the sandwich.

When interviewed on 1/12/12 at 1:52 PM, CNA #1 stated when she assists the resident she does not use gloves when she cuts the resident's sandwich and that she should have used the wrap, napkin or the fork instead of her hand to hold the sandwich.

2. Resident #505 has diagnoses including dementia. Review of the Minimum Data Set (MDS) dated 12/30/11 revealed the resident has moderately impaired cognition. Review of the current ADL Plan of Care printed 1/12/12 revealed that the resident requires set up help for meals.

When observed on 1/12/12 at 12:30 PM, CNA #2 opened the resident's bread and placed it in the palm of her ungloved and unsanitized hand and buttered it. The resident was observed to eat the bread.

A glove box with gloves and a bottle of hand sanitizer was observed in both the Unit K and Unit G dining room.

When interviewed on 1/12/12 at 1:20 PM, CNA #2 stated that resident's food should not be touched with bare hands. She stated she did not realize she touched the gelatin salad and bread. CNA #2 stated she should wear gloves when she touches the resident's food and stated that gloves are available in the dining room.

When interviewed on 1/12/12 at 1:30 PM, the Licensed Practical Nurse (LPN) Charge Nurse stated she assist in the Unit G dining room and stated that gloves should be worn if touching residents' food and that gloves are available in the dining room.

3. Resident #605 has diagnoses including anemia. Review of the Minimum Data Set (MDS) dated 11/8/11 the resident has moderately impaired cognition. Review of the current ADL Plan of Care printed 1/12/12 and the Comprehensive Care Plan dated 8/12/11 revealed the resident requires one person to physically assist with bathing.

When observed on 1/18/12 at 9:27 AM, CNA #3 washed their own hands, applied gloves, bathed the resident's upper body and dropped the wash cloth in the wash basin of soapy water. CNA #3 removed another washcloth from the same basin and rinsed the resident. CNA #3 then removed the gloves, washed their hands and reapplied gloves, and with the same washcloths, she washed the resident's buttock and rectal area and dropped the washcloths back into the basin of soapy water. The CNA then took a wash cloth from the basin and handed the wash cloth to the resident. The resident washed their peri area front to back and back to front.

When interviewed on 1/18/12 at 2:19 PM, CNA #3 stated that she should have had the resident wash their peri area before she washed the rectal area. She then explained she was taught to wash the peri area front to back and change the area of the washcloth with each stroke. She stated that the resident washed back and forth and that she should have washed the resident. CNA #3 confirmed that she put the used washcloths back in the basin and gave the resident the washcloth that was used on the rectal area to cleanse the peri area.

When interviewed on 1/18/12 at 2:36 PM, the Registered Nurse (RN) Head Nurse stated the CNA should change the water and gloves after washing the resident's upper body and before she cleansed the peri rectal area. She stated according to the facility policy the CNA should cleanse the resident's upper body, change the water, cleanse the thighs, peri area front to back, change the water and washcloth, cleanse both hips, buttock and cleanse the rectal area last, then remove gloves and wash hands. She further explained she would not have the resident cleanse the peri area because the resident would not do it effectively or properly.

Observation on 1/18/12 at 6:30 AM revealed the CNA was finishing providing incontinence care on the resident. Urine soaked incontinence pads were on the bed. The CNA removed the soiled pads from the bed with gloved hands and placed them on the floor. The CNA then left the room without removing the gloves and went into the clean utility room to get a sheet, drawsheet and incontinence pads.

An interview on 1/18/12 at approximately 12:30 PM with the Registered Nurse (RN) Staff Nurse/Acting Charge day shift, revealed that the CNA should have followed hand washing procedures after handling soiled linens.

415.19(a)(4)(c)

F166 483.10(f)(2): FACILITY RESOLVES RESIDENT GRIEVANCES

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

A resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

Citation date: January 20, 2012

Based on record review and staff, resident and family interview, the facility did not ensure that residents have the right to prompt efforts to resolve grievances the resident(s) may have. Four (Residents A, B, C, D) of four residents reviewed for grievances at the Erie County Medical Center SNF had issues involving delays in call bell response; staff turning off call bells at the nursing station and not answering the call bells; residents not getting out of bed; and/or not going to activities of their choice. One (Resident #309) of four residents reviewed for grievances at the Erie County Home had an incomplete investigation of missing personal items. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Medical Center SNF

1. Review of the Resident Council Meeting Minutes dated 9/11 through 12/11 revealed the residents complained that call bells are turned off at the nursing station and staff are not responding or staff sometimes take over one hour to respond to the call bells and residents are not able to attend their activity due to complaints of staffing shortages.

Additional review of the Resident Council Meeting Minutes revealed the following:

- On 9/28/11 - residents complained that there is not enough staff to get the residents up as per choice. The action was that the Team Leader was made aware. The outcome was documented that the residents are still unhappy about the situation and issues still remain. "Will re-address staffing with the Administrator".
- On 10/27/11 - residents complained of the following: staff turn off call lights at nursing desk and do not respond further, residents not out of bed as per their request. The action was notification of the DON (Director of Nursing), Nursing Supervisors and Team Leader and to continue to monitor the situation. Outcome: call lights still being turned off at desk and continue to monitor.
- On 11/23/11 - residents complained of not getting out of bed or the time as per their request and that call lights are turned off at the nursing desk. Action - Team leaders, DON notified and memo sent to Supervisors to monitor. Outcome: several issues getting better but one issue not resolved and will continue to monitor.
- On 12/29/11 - the issues identified that a resident was not assisted out of bed at the time the resident desires.

a). During an interview on 1/13/12 at 9:00 AM, Resident A stated that staff shut off call bells and do not come back or there is delay in staff answering call bells for over 1/2 to 1 hour during different shifts. The resident stated that residents on other floors also complain of waiting a long time for staff to answer call bells or not at all. The resident stated that residents bring it up over and over again at the Resident Council Meetings and the Administrator, Director of Nursing (DON) and Registered Nurse (RN) Team Leaders are well aware of the call bell problems. Resident A also stated that residents are not getting their showers and are not getting to go to activities when they want to go. The residents have complained at the Resident Council meetings that they want to get out of bed at a certain time (ex: before breakfast) but can't because there are not enough staff. The resident stated when you complain to the staff, the staff tells you, "There's not enough staff". Also the resident stated that residents complain that they do not get their showers on days when they are short staffed and have to wash up at the side of the bed and they do not like it.

b). During an interview on 1/13/12 at 2:10 PM, Resident B stated there is not enough staff to take care of the residents and it has been happening for quite awhile. The resident stated he has complained about being "left wet" (incontinent) sometimes for over an hour even though he has put his call bell on because "no one comes". The resident stated he has asked to speak with the Administrator. The resident stated he spoke to the Administrator, in October (10/11), soon after the Administrator started at the facility, and complained that care was not being provided to the residents because there was not enough staff. The Administrator told the resident that he would look into it. The resident stated "nothing has changed".

c). During an interview on 1/18/12 at 4:00 PM, Resident C stated that staff sometimes take more than 1 hour to answer his call bell or sometimes the staff shut the call bell off in the office and never come. The resident stated that he doesn't get out of bed when he wants to and sometimes misses activities because there are not enough staff. The resident stated on Tuesday (1/17/12) he had to transfer himself from the bed to the wheelchair with his transfer device because the staff could not help him finish getting out of bed so he could go to play cards with his friends that afternoon. The resident also stated he has complained every month for a long time at the Resident Council meetings but nothing has been done.

Interview on 1/19/12 at 11:45 AM with certified nurse aide (CNA) #3 revealed she worked with the resident on Tuesday 1/17/12 and the resident wanted to stay in bed when she (CNA) asked him (resident) that morning. CNA# 3 stated the resident asked her later in the day to get up and she assisted the resident but didn't transfer him from the bed to the wheelchair because she left to assist another resident. CNA #3 stated by the time she helped the other resident it was the end of her shift and had to leave but did tell a CNA coming on duty that the resident was not out of bed. CNA #3 stated sometimes she is scheduled with 14 residents to take care of and most of the residents can be total care.

d). When interviewed on 1/19/12 at approximately 12:00 PM, Resident D stated that on at least three occasions, the staff did not get her out of bed on time to go to church which upset her. The resident stated that the staff told her that they did not have enough staff on duty to provide personal care and transfer her out of bed in time to go to church.

During an interview with the Administrator and the DON on 1/18/12 at approximately 5:00 PM, the Administrator stated he was aware of the residents' care concerns regarding delays in call bell response and residents not getting out of bed. The Administrator stated he is working with the Vice-President in fast tracking hiring of staff because there are ongoing issues. During the interview, the DON stated residents' concerns regarding not getting out of bed is an ongoing concern and Nursing Supervisor continues to look at the issue. The DON stated that call bell audits were done, however the audits were not provided when requested by the surveyor.

Review of a document entitled Your Rights as a Nursing Home Resident in New York State and Facility Responsibilities dated 3/92 (attached to the facility Protocol for Residents' Bill of Rights dated 7/24/92) revealed the section titled Grievances documented that a resident has the right to prompt resolution of grievances and that the facility is to ensure that a method is in place to respond within 21 days to the grievances.

Review of a facility policy and procedure (P&P) entitled Complaint/ Grievance Procedure for Residents with a revision date of 9/5/95 revealed upon receipt of a completed complaint form, the staff person receiving the complaint/ grievance will forward it to their department head. The department head will begin investigation of the complaint and notify the Administrator immediately. Upon receipt of the complaint, the SNF Administrator will assure that it is addressed in a timely fashion and will notify the person filing the complaint within 21 days.

During an interview on 1/19/12 at approximately 5:15 PM, the Activity Director stated that she assists the residents at the Resident Council meetings. The procedure is that when a resident or residents have concerns, a Resident Concern form is filled out and sent to the department responsible for correcting the concern. Any follow-up is presented to the residents at the next meeting.

Erie County Home

2. Resident #309 has diagnoses of dementia and peripheral edema. Review of the Minimum Data Set (MDS) dated 10/28/11 revealed the resident has severe cognitive impairment.

During an interview on 1/13/12 at 10:45 AM, a family member stated that about one month ago, she reported to a nurse that the resident's watch, shoes, and two pairs of Velcro sneakers were missing. The family member stated that staff response was not satisfactory and the watch is still missing.

During an interview on 1/18/12 at 11:51 AM, the Social Worker stated missing items are documented on a Resident Concern Form and any staff member can complete the form. The Social Worker explained that most of the time the Head Nurse fills it out. The Resident Concern Form is sent to administration where the Administrative Secretary reviews the form and it is sent to the appropriate department for investigation. The Social Worker stated an investigation is continued until the item is found or the investigation is exhausted.

Review of a Resident Concern Form for Resident #309 dated 8/14/11 revealed the following items were missing:

After reviewing the Resident Concern Form dated 8/14/11, the Social Worker stated there was no indication that the button down yellow dress shirt, the seersucker shirt, the yellow jogging pants, the black sweat pants, or the ankle socks were found. The Social Worker explained that Part II (Investigation) and Part III Outcome and Action taken) on the Form should have been completed by Nursing and Laundry. The Social Worker reviewed a Letter from Administration that was attached to the Form indicating that the resident's missing items were found and returned. The Social Worker stated she was not sure whether the items were ever returned. The Social Worker also stated that she was not aware that Resident #309 was missing a watch and two pairs of Velcro sneakers and there was no Resident Concern Form for these items.

When interviewed on 1/18/12 at 12:53 PM, the Social Worker stated she called the resident's family member, who stated she reported the lost items (the watch and Velcro sneakers) to the evening Licensed Practical Nurse (LPN).

During an interview on 1/18/12 at 3:20 PM, an evening shift Licensed Practical Nurse (LPN) stated Resident #309's family reported missing sneakers and clothing. The LPN stated she first looks for missing items and usually finds them and if she does not find the missing items, she leaves a note for the next shift. The LPN stated the policy is to make out a Resident Concern Form but she does not make the form out because staff either usually find the items or they are in the laundry. The LPN stated when a family member tells her clothing is missing, "I tell them they are in the laundry". The LPN stated she does not remember that Resident #309's family reported a missing watch.

When interviewed on 1/18/12 at 3:45 PM, an evening shift certified nurse aide (CNA) stated she heard the family member tell the evening shift LPN that Resident #309 was missing clothing. The CNA stated the resident was missing shoes but has the shoes now. The CNA also stated she was not aware that the family reported a missing watch.

When interviewed on 1/19/12 at 11:54 AM, the Administrator stated when the Resident Concern Form is made out it goes to the Administrative Assistant who reviews it and then it goes to the appropriate departments and they respond back to her.

When interviewed on 1/19/12 at 11:56 AM, the Administrative Assistant stated the process for the Resident Concern Form for missing items would be to send a copy of the report to nursing and laundry, who then return the form with Parts II and III completed. The Administrative Assistant stated a letter was sent to the family indicating that the items were found. After review of the Resident Concern Form dated 8/14/11 she stated she must have glanced over the form and did not look at it closely to see if all the items were found before sending the letter out. The Administrative Assistant stated "Obviously all the items were not found".

The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under ¾1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing.
The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section.
The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.
The facility must furnish a written description of legal rights which includes:
A description of the manner of protecting personal funds, under paragraph (c) of this section;
A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels.
A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements.
The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law.
The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care.
The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Citation date: January 20, 2012

Based on record review and staff interview, the facility did not inform each resident or the resident's representatives during the resident's stay, of charges for services not covered under Medicare. Four (Residents #1, 301, 344, 530) of four residents reviewed for notification of Medicare Non-Coverage and Liability at both the Erie County Medical Center SNF and at the Erie County Home did not receive Liability Notices when payment for skilled services ended and the residents remained in the facility. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

Erie County Home

1. Resident #1 was admitted to the Erie County Home on 6/7/11 with diagnoses including hypertension, multiple sclerosis (MS) and depression. Review of the Minimum Data Set (MDS) dated 12/13/11 revealed that the resident is cognitively intact, understands and is understood.

Review of a Notice of Medicare Non-Coverage dated 6/17/11 revealed the resident received notification that Medicare coverage for skilled services would end on 6/20/11. Review of the Alphabetic Resident Listing printed 1/12/12 revealed that the resident continued to reside in the facility as of 1/12/12.

Additional review of the medical record revealed no documented evidence that a Liability Notice was provided to the resident/resident's representative when covered services ended on 6/20/11.

2. Resident #344 was admitted to the Erie County Home on 7/23/11 with diagnoses of hypertension, diabetes mellitus and dementia. Review of the MDS dated 8/5/11 revealed the resident has severe cognitive impairment, has short and long term memory problems, sometimes understands and is rarely/never understood.

Review of a Notice of Medicare Non-Coverage dated 8/5/11 revealed the resident's representative received verbal notification that Medicare coverage for skilled services would end on 8/10/11. Review of a Discharge MDS dated 8/21/11 revealed the resident was discharged from the facility on 8/21/11.

Additional review of the medical record revealed no documented evidence that a Liability Notice was provided to the resident/resident's representative when covered services ended on 8/10/11.

Erie County Medical Center SNF

3. Resident #301 was admitted to the Erie County Medical Center SNF on 8/16/11 with diagnoses of hypertension, diabetes mellitus and cerebrovascular accident (CVA - stroke). Review of the MDS dated 11/15/11 revealed that the resident has severe cognitive impairment, has short and long term care problems, understands and is understood.

Review of a Notice of Medicare Non-Coverage dated 9/7/11 revealed the resident/ resident's representative received notification that Medicare coverage for skilled services would end on 9/9/11. Review of a Discharge MDS dated 11/28/11 revealed the resident was discharged from the facility on 11/28/11.

Additional review of the medical record revealed no documented evidence that a Liability Notice was provided to the resident/resident's representative when covered services ended on 9/9/11.

Interview with a Medical Records Technician at the Erie County Home on 1/17/12 at 2:35 PM revealed the MDS Nurses send out the Medicare Notices (for non-coverage) and they are not sending out liability notices.

Interview with a Registered Nurse (RN) Charge Nurse/MDS Nurse (#1) at the Erie County Home on 1/17/12 at 2:40 PM revealed that she gives the Notice of Medicare Provider Non-Coverage letters to the residents when Medicare coverage ends and she gives them the notification ahead of time. The MDS Nurse (#1) stated one of the other MDS nurses went to a seminar regarding Medicare notifications and found out there should be another letter given to the residents, but "we didn't know what it was". "We went to the CMS website and asked administration, but we have not figured out what other letter we should be sending out".

Interview with an RN Charge Nurse/MDS Nurse (#2) at the Erie County Home on 1/18/12 at 8:49 AM revealed that she attended a Medicare Seminar last summer and "it was alluded that there were more forms that we are supposed to use when residents are cut from Medicare". The MDS Nurse stated "I talked to administration, and they suggested we talk to Medical Records, I followed up a number of times and we have not gotten anything back. All the records are in Medical Records, so if there were Liability Notices issued the copies would be there. We would have to have someone in another department compose a letter for us to use".

Further interview with the Medical Records Technician on 1/18/12 at 9:02 AM revealed that she checked with the Erie County Medical Center SNF and they are not providing residents with notice of liability when Medicare coverage ends.

Interview with the Operations Manager who is a Physical Therapist on 1/19/11 at 5:20 PM revealed that the facility has no policy regarding providing residents a Notice of Liability.

415.3(g)(2)(iii)

F170 483.10(i)(1): RESIDENT CAN SEND/RECEIVE UNOPENED MAIL

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

The resident has the right to privacy in written communications, including the right to send and promptly receive mail that is unopened.

Citation date: January 20, 2012

Based on observation, record review, and staff and resident interview, the facility did not promptly send and receive mail. One (Erie County Home) of two facility locations had an issue with residents not receiving mail on Saturdays. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. On 1/17/12 at 9:45 AM, the Resident Council President (Resident #1) was interviewed in his room. As president of the Resident Council, the resident speaks for all residents residing in the facility. When questioned about mail delivery, the resident stated he did not think that mail was delivered to the Erie County Home on Saturdays. The resident said he has been President of the Resident Council for several years, and assumed not receiving mail on Saturdays was normal procedure. The resident stated he would like to see mail delivered on Saturdays if it was possible.

Interview with the Registered Nurse (RN) Nursing Coordinator on 1/18/12 at 8:30 AM revealed that the Postal Service does not deliver mail to the facility on Saturdays and this has been the Postal Service policy for many years. At the time of the interview, the mail box at the front entrance of the Erie County Home was observed to have a sign attached to it which excluded Saturday mail delivery.

Interview with the Administrator and the Director of Support Services on 1/19/12 at approximately 2:00 PM revealed that the Administrator was unaware that residents were not receiving their mail on Saturdays. The Director of Support Services stated he had phoned the Postal Service on 1/18/12 (after the surveyor had made inquiry) and learned that Saturday mail delivery has not been provided for many years to the Erie County Home at the request of the facility. The Postal Service said they could not say exactly how many years ago this request was made by the facility, but that the request was made because there was no one available at the Erie County Home front desk or business office to accept mail from the carrier.

During an interview on 1/19/12 at approximately 4:00 PM, the Administrator stated that the Postal Service has been advised to begin mail delivery to the Erie County Home on the next Saturday, 1/21/12.

During an interview on 1/19/12 at approximately 4:30 PM, the Resident Council President was informed that Saturday mail delivery would be starting. The President of the Resident Council said he was happy to hear this for all the residents in the facility.

415.3(d)(2)(i)

F161 483.10(c)(7): SURETY BOND OR OTHER ASSURANCE

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.

Citation date: January 20, 2012

Based on record review and staff interview, the facility did not provide evidence that the facility purchased a surety bond or otherwise provided assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. The facility did not have a surety bond or similar protection with an amount equal to at least the current total amount of 632 of 632 residents' personal funds deposited with the facility. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Interview with the Administrator of the Erie County Home on 1/18/12 at approximately 3:30 PM revealed that the facility has a Surety Bond.

Review of the Surety Bond entitled "Residents' Personal Funds Trust Fund" revealed the fund covers all residents of both the Erie County Home and the Erie County Medical Center SNF, who have personal funds deposited with the two nursing facilities. The Surety Bond documented that the security of all personal funds deposited was assured for a total sum of Fifty Thousand Dollars ($50,000).

Interview with the Cashier at the Erie County Home on 1/19/12 at approximately 3:05 PM revealed the residents' personal accounts at the Erie County Home amounted to $357,963.32 and the residents' personal accounts at the Erie County Medical Center SNF amounted to $58,280.41. As of 1/19/12, the total balance of the personal accounts for 632 residents from both of the nursing facilities was $416,243.73.

An interview with the Administrator of the Erie County Home on 1/19/12 at approximately 4:50 PM revealed the facility's current Surety Bond of $50,000.00 does not cover the residents' present personal account balance of over $400,000.00.

415.26(h)(5)(v)

F312 483.25(a)(3): ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Citation date: January 20, 2012

Based on observation, record review and staff and resident interview, the facility did not provide the necessary services to maintain good grooming, and personal and oral hygiene for a resident who is unable to carry out activities of daily living. One (Resident #448) of four residents at the Erie County Medical Center SNF, who is totally dependent on staff for activities of daily living (ADL), did not receive proper hygiene to remove a large accumulation of oral secretions. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #448 has diagnoses including respiratory failure, a tracheostomy (surgically created hole in the front of the neck and into the windpipe) with ventilator support and is aphasic (absence or difficulty with speech). Review of the Minimum Data Set (MDS) dated 11/1/11 revealed the resident is cognitively intact for daily decision making, is sometimes understood and usually understands. The MDS documented that the resident is totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing.

Interview with the Registered Nurse (RN) Team Leader on 1/13/12 at 2:15 PM revealed the resident communicates via a computer using a voice synthesizer device.

During an interview on 1/13/12 at 2:30 PM, the resident communicated using a specialized computer and stated that the staff do not follow his requests and disregard his concerns. The resident was asked to demonstrate how he activates the call pad system and the resident demonstrated by lifting his left foot and activating the call system.

Review of an MD (medical doctor) Note dated 12/11 revealed the resident has a contracture (loss of joint mobility) of his neck which bends his neck and head to the left but (the resident) refuses a neck positioning device.

Review of the CarePlan, used by certified nurse aides (CNAs) to provide care, dated 9/25/11 revealed instructions to place disposable wipes under the left side of the resident's face.

Review of the Comprehensive Care Plan (CCP) dated 11/18/11 revealed the resident is alert and oriented x 3 (to person, place and time); is able to make his needs known; has an alteration in communication related to his diagnosis and is vent dependent with a trach (tracheostomy). The CCP documented that the resident is unable to speak; he tries to mouth words but it is difficult to make out and he shakes his head in response to questions. CCP approaches include, but are not limited to:

- the use of communication devices,
- staff are to allow plenty of time for communication and wait for resident to respond,
- staff are to pay attention to what the resident is communicating non-verbally,
- answer the call light promptly.

Further review of the CCP revealed the resident has a self care deficit and is dependent on staff for all ADLs. Approaches include total staff assistance for oral care and bathing and a plan to place disposable wipes under the left side of the resident's face.

Observation on 1/18/12 from 10:55 AM through 12:30 PM revealed CNA #1 and CNA #2 washed the resident's face. The resident's head and neck were bent to the left and white disposable cloths were tucked in the resident's neck to the left of the trach, between the resident's left cheek and left shoulder area. CNA #2 moved the resident's head slightly to the right away from his body. CNA #1 was observed to wash around the disposable cloths but not under them and the resident was observed to "make a face". The disposable cloths were saturated with thick, clear oral secretions. CNA #1 removed her gloves and enter the resident's bathroom to change the bath water.

The resident indicated that he wanted to tell the CNA something. CNA #2 obtained the resident's cardboard communication board and asked the resident to indicate which row he wanted to spell out what he wanted alphabetically. After approximately 5 minutes of using the cardboard communication board with the resident, CNA #1 replaced an electronic dot on the resident's nose, to activate the computer so he could communicate with the staff. While the resident was using his communication device, the RN Team Leader entered the room at 11:40 AM and asked CNA #1 if she was done with the resident. CNA #1 stated that she had not washed the resident's back yet and was waiting for the resident to finish spelling something on his computer. After the resident spelled out what he wanted to say on his computer, the computer's voice activated and read the resident's statement, "I have told you over 50 times at least that you (CNA #1) never wash under the wipes (disposable cloths)".

While the resident was still using his computer to communicate with CNA #1, the RN Team Leader entered the resident's room at 11:40 AM and stated to the resident that the CNA had other people to do and the resident could type out what he wanted when they were done with his care. The resident continued to spell out that the CNA never washes under the wipes (disposable cloths). The RN Team Leader stated to the resident that CNA #1 "can rewash the area if you want?". The resident continued spelling out words and again the RN Team Leader stated that the CNA needs to finish the resident's care. The resident communicated that he feels that the RN Team Leader is not validating his (resident's) concerns and communicated that the RN Team Leader was trying to "cut him off". The RN Team Leader stated that she was not minimizing his concerns or trying "to cut you off" but the CNA had other people to take care of.

At 11:58 AM, the resident gave permission to continue his care. The RN Team Leader stated the resident needed to be suctioned first. The RN Team Leader was observed to suction the resident's tracheostomy tube and his mouth. A large amount of thick, clear secretions were suctioned from the resident's mouth. CNA #1 moved the resident's head and removed the disposable cloths that collect the secretions. The CNA was observed to remove the cloths to wash the resident's neck area and there was a copious amount of secretions under the pads on the resident's neck. CNA #1 washed, rinsed and dried the area.

Interview with the RN Team Leader on 1/18/12 at approximately 12:35 PM revealed all of the staff are frustrated with the resident and have tried everything to accommodate the resident and "nothing seems to work". The RN Team Leader stated CNA #1 should have washed under the resident's disposable cloths.

Interview with CNA #1 on 1/18/12 at 2:55 PM confirmed that she wiped around the disposable cloths on the resident's neck but did not wash underneath them until the resident requested her to do so.

Interview with the resident on 1/18/12 at approximately 3:30 PM revealed that he felt very frustrated with the staff because she (CNA #1) has been told at least 50 times that she needs to wash under the pads (to catch his secretions). The resident communicated that it was uncomfortable to have all that "slimy spit" under the pads and not be cleaned properly and he was worried that his family would see him like this.

Review of the facility policy entitled Bathing with a revision date of 11/1996 revealed the staff is to wash the resident's face, neck and ears.

The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment.
A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Citation date: January 20, 2012

Based on record review and staff interview, the facility did not periodically review and revise the comprehensive care plan (CCP). One (Resident #539) of six residents reviewed for pressure ulcers at the Erie County Medical Center SNF had an issue involving the lack of CCP revisions to address the locations of new and existing pressure ulcers and changes in treatment. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Review of the Comprehensive Care Plan (CCP) printed 8/30/11 revealed the resident had two unhealed Stage 3 pressure ulcers. Documentation on the care plan dated 8/29/11 revealed an ID (Infectious Disease) consult and a Wound Team Consult were ordered.

Review of the History and Physical, completed by the Physician, dated 8/26/11 revealed the resident had a Stage 3 sacral decubitus measuring 3 x 3, a Stage 4 decubitus on the right upper thigh area measuring 4 x 4, and a Stage 2 on the bilateral heels.

An ID Report of Consultation dated 8/30/11 documented the resident had the following decubitus ulcers:

The ID Physician documented the resident had an infection of the right glutial decubitus and the "coccyx right ishium now covered with a wound vac" (vacuum - therapeutic device using a vacuum dressing to promote wound healing).

Additional review of the CCP dated 8/30/11 revealed there were no revisions to the care plan reflecting the locations of multiple ulcers, measurement changes, the presence of infection or treatment changes.

Interview with the Director of Nursing (DON) on 1/19/12 at 1:00 PM revealed care plans are updated episodically as issues arise and with quarterly reviews.

415.11(c)(2)(iii)

F431 483.60(b), (d), (e): PROPER LABELING OF DRUGS AND BIOLOGICALS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED 2/27/09, 1/29/10 and 12/10/10.

Based on observation, record review and staff interview, the facility did not ensure proper storage of drugs and biologicals including controlled substances. Two (6th Floor Zone 4, 5th floor Sub-Acute Unit) of seven zones observed for storage of drugs and biologicals at the Erie County Medical Center SNF had issues involving an unlocked and unattended medication cart that contained medications that had been prepared but not administered to a resident and controlled substances that were stored in an unattended and unsecured medication cart between use. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. On 1/12/12 between 12:10 PM and 12:25 PM the 6th Floor Zone 4 medication cart was observed to be unlocked and unattended in the hallway. The Medication Nurse was not observed at or around the medication cart. During this time, one resident, one visitor and one staff walked past the medication cart and one ambulatory resident was sitting in the vicinity of the cart. The medication cart contained medications that were poured in a cup but not administered for one resident. The medication cup contained Aspirin (pain medication) 81 milligrams (mg) one tablet, Digoxin (cardiac medication used to treat irregular heart rate) 0.25 mg one tablet, and Carvedilol (cardiac medication used to treat heart failure) 25 mg one tablet.

When interviewed on 1/12/12 at 12:25 PM, the Licensed Practical Nurse (LPN) on the 6th Floor Zone 4 said that she is the Medication Nurse responsible for the medication cart today. The LPN Medication Nurse stated that she had a resident's medications already poured in a cup in the drawer of the medication cart. She was observed to remove the medication cup from the top drawer of the unlocked medication cart and give the medications to the resident. The LPN Medication Nurse stated that she usually locks her cart before walking away but forgot. The LPN said she was going to go to lunch after she locked up the controlled meds in the medication room. She said the medication room is located on Zone 3 which is down the hallway and around the corner on the other unit on the 6th Floor.

An interview with the Registered Nurse (RN) Team Leader for the 6th Floor Zone 3 and 4 on 1/12/12 at 12:45 PM revealed that medication carts are to be locked when not in use and/or unattended. The RN Team Leader stated both of the residents observed in the vicinity of the medication cart were cognitively aware and both residents were independent in ambulation.

2. On 1/12/12 at approximately 11:45 AM, a medication cart was observed in the hallway on the 5th floor Sub Acute Unit. The cart was locked, unattended and untethered.

On 1/12/12 at approximately 11:50 AM, the Licensed Practical Nurse (LPN) said that she routinely stores controlled substances in the medication cart until the end of the shift and then returns them to the double locked medication cabinet.

At this time, the LPN opened a double locked compartment in the medication cart. Inside the compartment were the following:

Review of the facility policy and procedure entitled Addendum to Controlled Substance Policy and Procedure, revised 1/26/10 revealed that during a routine medication pass, controlled substances may be stored in the double locked compartment in the medication cart. The narcotics are then to be returned to the main narcotic cabinet once the medication pass is completed.

An interview on 1/19/12 at 1:00 PM with the Registered Nurse (RN) Head Nurse revealed that all controlled substances are to be locked in the double locked medication cabinet between medication passes.

415.18(e)(1)(2)

F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Citation date: January 20, 2012

Based on observation, record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment and care plan. Two (Residents #309, 539) of 51 residents reviewed for quality of care at both the Erie County Home and the Erie County Medical Center SNF had issues with a physician order for Ted Stocking (thromboembolism deterrent stockings - elastic stockings used to prevent blood clots) that were not applied (#309), and lack of comprehensive weekly assessments of heel ulcers, including measurements of size (#539). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Resident #309 has a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated 10/28/11 revealed the resident has severe cognitive impairment.

Review of a Physician's Telephone Order dated 12/20/11 revealed an order to obtain a Venous Doppler (diagnostic test to evaluate blood circulation) of the bilateral lower extremities to rule out DVT (deep vein thrombosis - obstruction in a blood vessel due to a blood clot).

A Physician Acute Visit Note dated 12/22/11 documented that the resident's extremities had "1 + edema" (swelling) bilaterally and were symmetrical (the same on both sides) without a Homen's sign (an examination procedure to determine the presence of a DVT), redness or warmth. The Physician documented a plan for Ted Stocking and monitor. Review of a Physician's Order dated 12/22/11 revealed an order for TED Stockings on in the AM and off at HS (hour of sleep/bed time).

Review of the ADL (activities of daily living) Plans of Care dated 1/12/12 revealed a plan to provide Ted Stockings, on in the AM and off at HS.

Observation on 1/17/12 at 1:30 PM revealed the resident was ambulated to the bathroom for incontinence care by a certified nurse aide (CNA #1). The resident had ankle length socks on and no Ted Stockings.

Observation of 1/17/12 and 1/18/12 revealed the following:

- On 1/17/12 at 1:59 PM, the resident was sitting in a chair in the hall. The resident's pants were pulled up and bilateral ankle socks were observed. There were no Ted Stockings and the resident's left ankle was observed to be edematous.
- On 1/18/12 at 9:17 AM, the resident was sitting on the edge of the bed eating breakfast. The resident was wearing ankle socks and no Ted Stockings.
- On 1/18/12 from 10:02 AM to 11:00 AM, the resident was sitting in a chair in a dementia activities program. The resident was wearing socks and sneakers and did not have Ted Stockings on.
- On 1/18/12 at 12:10 PM, the resident was sitting in the Unit G dining room. At 12:58 PM, CNA #2 ambulated the resident to the bathroom. The resident was wearing ankle length socks and no Ted Stockings.

During an interview on 1/18/12 on 1:01 PM, CNA #2 stated she washed and dressed the resident that morning. The CNA stated the resident always wears socks and she has never put Ted Stockings on the resident. The CNA stated she would check the Accu Nurse (voice activated computerized system containing the care plan and where CNAs document care provided) to see if Ted Stockings were in there.

On 1/18/12 at 1:08 PM, CNA #2 was observed to go to the resident room, and after checking in the resident drawer, stated there were no Ted Stocking in the drawer.

When interviewed on 1/18/12 at 1:13 PM, the Registered Nurse (RN) Head Nurse stated the CNA is responsible for putting the Ted Stocking on the resident. The RN Head Nurse stated the CNA should listen to the Accu Nurse system and the Ted Stockings would be included under "dressing" so the CNA would know they have to apply Ted Stockings. The RN Head Nurse explained that the CNAs do not document that they put Ted Stockings on. The Ted Stockings are ordered by the nurses from Central Supply and the RN Head Nurse stated she would check to see when they were ordered.

During an interview on 1/18/12 at 1:58 PM, CNA #1 stated she has cared for the resident since he has been here. The CNA stated there would be a doctor's order for the Teds Stockings and she assumed that the nurse would order the Ted Stockings for the resident. The CNA stated the Ted Stockings used to be documented on the Treatment Record and she considers it a nurses' treatment to put the Ted Stockings on. CNA #1 explained the Accu Nurse system is used by both the nurses and the CNAs and that Ted Stockings are under "dressing". CNA #1 stated she has never put Ted Stockings on the resident but if the resident had them, she would have put them on.

On 1/18/12 at 2:08 PM, CNA #1 reviewed the ADL Plans of Care dated 1/12/12 and stated the Ted Stocking are on the care plan. CNA #1 stated she is expected to follow the ADL Care Plan for the resident.

When interviewed on 1/18/12 at 2:12 PM, the RN Head Nurse stated the ADL Plans of Care is what the CNA follows for the Plan of Care.

When interviewed on 1/18/12 at 2:51 PM, the RN Head Nurse stated she obtained the Ted Stockings from Central Supply and they are checking to see if they were previously sent.

Review of a Fax Transmission Verification Report dated 12/21/11 at 8:44 PM revealed the 12/22/11 Physician's Order for Ted Stockings for Resident #309 was sent to Central Supply.

On 1/18/12 at 3:00 PM, the RN Head Nurse was observed to remove the resident's ankle socks and stated the resident has "2+ edema" from his ankles to upper calf. The RN Head Nurse stated she would have the resident rest in bed for awhile before putting the Ted Stockings on.

2. Resident #539 has diagnoses which include traumatic spinal cord injury, paraplegia (paralysis of the lower extremities), and an infected Stage 3 sacral pressure ulcer. Review of the Minimum Data Set (MDS) dated 8/19/11 revealed the resident has independent decision making ability.

Review of the Nursing Admission Assessment dated 8/11/11 revealed the resident was admitted to the facility from the hospital with a Stage 3 decubitus (pressure ulcer) on the sacrum measuring 3 x 3 centimeters (cm), a Stage 4 decubitus on the right upper thigh measuring 4 x 4 cm, and blackened areas on bilateral heels.

Review of "Weekly Wound Assessment by RN" (registered nurse) Sheets for both the left and right heels dated 8/11/11 to 8/26/11 revealed the resident's heels were assessed as follows:

- On 8/11/11 and 8/17/11, both heel wounds were unstageable, black/dark and measured 2 cm long by 2 cm wide.
- On 8/26/11, both heel wounds were unstageable, "blackened" and measured "2 cm round". The Wound Assessment Sheets documented that Skin Prep (topical application that toughens skin) was applied to both heels BID (twice a day) per the admission orders.

Review of the History and Physical, completed by the Physician, dated 8/26/11 revealed the resident had a Stage 3 sacral decubitus measuring 3 x 3, a Stage 4 decubitus on the right upper thigh area measuring 4 x 4, and a Stage 2 on the bilateral heels.

An ID (Infectious Disease) Report of Consultation dated 8/30/11 documented the resident had the following decubitus ulcers:

The ID consult lacked documentation of the status of the bilateral heel ulcers.

Interview with the RN Inservice Education Nurse on 1/19/11 at approximately 2:45 PM revealed the ID Team focus their attention on the more serious areas and they would not have looked at the resident's heels. The RN Inservice Education Nurse stated nursing should still have measured the areas and documented them on the skin sheet.

Further review of Weekly Wound Assessment by RN sheets revealed there were no further measurements of the left and right heel ulcers after 8/26/11.

Review of a Podiatry Record dated 8/31/11 revealed the resident had PVD (peripheral vascular disease - poor circulation of the lower extremities) of both lower extremities.

Review of an untitled document, provided to the surveyor by the facility on 1/19/12, revealed in accordance with their guidelines the resident's heels were no longer considered pressure ulcers due to the diagnosis of PVD and were now considered stasis ulcers (skin breakdown related to impaired circulation in the lower extremities). Additional review of the document revealed the treatment with skin prep continued and weekly monitoring was changed to a daily documentation sheet to coincide with wound treatments.

Review of the Daily Wound/Pressure Ulcer monitoring form dated 9/1/11 to 9/22/11 revealed there was documentation regarding drainage, odor, pain, surrounding tissue, and the wound bed. The form lacked documentation regarding ongoing measurements of the size of the stasis ulcers.

Based on a resident's comprehensive assessment, the facility must ensure that a resident -
(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and
(2) Receives a therapeutic diet when there is a nutritional problem.

Citation date: January 20, 2012

Based on record review and staff interview, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. One (Resident #539) of five residents reviewed for nutrition at the Erie County Medical Center SNF had issues involving the lack of an accurate Initial Nutrition Assessment to determine the resident's protein needs, a lack of evaluation of intakes for adequacy, a lack of re-evaluation of the resident's nutritional status following development of a Stage 4 pressure ulcer, and a lack of evaluation of a weight change and a low albumin level. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #539 has diagnoses including traumatic spinal cord injury, paraplegia (paralysis of lower extremities), and an infected Stage 3 sacral decubitus ulcer. Review of the 8/11/11 hospital Discharge Summary revealed that the resident had (1) Stage 3 sacral ulcer and (1) Stage 4 infected right buttock ulcer. Review of the Minimum Data Set (MDS) dated 8/19/11 revealed the resident was admitted on 8/11/11 and is cognitively intact. The MDS included that the resident's weight was 122 pounds (#), his height was 67" and has no or unknown weight loss. The MDS also identified that the resident has (1) Stage 3 pressure ulcer, (1) Stage 4 pressure ulcer and (2) unstageable pressure ulcers, all present on admission.

Review of the undated Admission/Readmission Report revealed the resident had a Stage 3 decubitus, a Stage 4 decubitus and blackened areas on bilateral heels.

Review of the Initial Nutrition Risk Assessment for Short-Term Stay completed by the Registered Dietitian (RD) and dated 8/19/11 revealed the resident's hospital weight was 122 pounds (#) and that the resident was underweight and had an infected Stage 3 pressure ulcer on the right buttocks. No pertinent labs were noted and there was no acknowledgement of the Stage 4 ulcer or blackened heels. The assessment included that the resident's estimated nutrients needs were 1886 calories, 72 grams protein and 1600 to 1700 milliliters of fluid per day and these needs were estimated based on the resident's current weight. The assessment included that the resident's diet order was for a regular diet with double portions and Ensure (liquid nutritional supplement). The assessment also included that the resident had a fair appetite but did not include an evaluation of the intakes for adequacy. Interventions included to monitor weight monthly/weekly and monitor labs.

Review of the Comprehensive Care Plan for Nutritional Status included approaches to monitor the resident's intake, weigh monthly and record and monitor the resident's monthly weight and report changes of +1 -5# to RD.

Review of the Resident Weight Record revealed one recorded weight of 124.5# on 8/23/11.

Review of an Infectious Disease Consult dated 8/30/11 revealed the resident had one Stage 3 and two Stage 4 pressure ulcers.

Review of an Interdisciplinary Communication form dated 9/12/11 revealed a notification from Dietary to Nursing that a weight was needed on the resident. Review of an untitled list of resident weights provided during the survey revealed that the resident had a September weight of 168#. There is no documented evidence of a re-weight to verify the accuracy of the weight or to assess the difference between the August and September weights.

Review of Nutrition Care Progress Notes revealed no documented evidence that the resident's nutritional status, including weight, skin and labs was reassessed or that the intakes were evaluated for adequacy after 8/19/11.

Review of the facility policy entitled Weights dated 4/08 revealed admission weights are to be done on the shift of admission and weekly for 4 weeks. The policy also includes that weights of plus or minus 5 pounds require an immediate reweigh and reweights are to be done within 24 hours.

When interviewed on 1/18/12 at approximately 1:40 PM, the RD said she was not aware of the resident's Stage 4 pressure ulcers and that the resident's protein needs should have been estimated higher. She said that she should document on new and worsening pressure ulcers weekly. She also said that admission weights should be obtained within 48 hours of admission and that the hospital weight was used because no weight had been obtained for the resident at the time of the assessment on 8/19/11. The RD confirmed that there were no other weights obtained besides on 8/23/11 and 9/11.

The RD also said that the resident received Ensure with meals and that an intake study was not done to assess if actual intake was meeting the resident's nutritional needs. The RD stated they used the consumption sheets to evaluate food and fluid intake, however supplement acceptance was not documented.

A resident has the right to receive notice before the resident's room or roommate in the facility is changed.

Citation date: January 20, 2012

Based on record review and staff and resident interview, the facility did not ensure residents' rights to receive notice before a room or roommate in the facility is changed. One (Resident #408) of one resident reviewed for Admission/ Transfer/ Discharge at Erie County Medical Center SNF did not receive notification prior to roommate changes. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #408 has diagnoses including diabetes mellitus, coronary artery disease, and hypertension. Review of the Minimum Data Set (MDS) dated 10/7/11 revealed the resident is cognitively intact for daily decision making, understands and is understood.

During an interview on 1/13/12 at approximately 1:47 PM, the resident stated he was never notified of a roommate change and he has had at least two new roommates during the past year.

When interviewed on 1/19/12 at approximately 9:00 AM, the resident stated he should be informed when he gets a new roommate because he would like to know.

Review of the Social Services section of the resident's chart revealed there was no documented evidence that the Social Worker had informed Resident #408 that he would be getting new roommates.

Interview with the Social Worker (SW) on 1/19/12 at approximately 11:15 AM revealed she mentions to the residents if they are changing roommates but does not document it. The SW stated that due to short staffing in the SW Department she was the only SW for months and with the budget cutbacks she cannot get to everyone. The SW stated if the resident stated no one told him then it "Has to be true".

Review of the facility Protocol for Resident's Bill of Rights dated 7/24/92 revealed there was no procedure for the resident to be informed of a roommate change.

The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 2/10/10.

Based on observation, record review, and staff and resident interview conducted during a complaint investigation (complaints #NY00109167, NY00110186) during the Standard survey completed 1/20/12, the facility did not ensure that services were provided by qualified persons in accordance with each resident's written plan of care. Three (Residents #3, 282, 439) of 26 residents reviewed for care plans at both the Erie County Home and the Erie County Medical Center SNF had issues involving a pressure relief mattress that was not provided (#439), lack of application of barrier cream after urinary incontinence (#282), and a lack of playing a radio in a resident's room (#3). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Resident #439 has diagnoses of morbid obesity and respiratory failure with a tracheostomy (surgically created hole in the front of the neck and into the windpipe). Review of the Annual Minimum Data Set (MDS) dated 11/18/11 revealed the resident is cognitively intact, always understands, is always understood, and is frequently incontinent of urine and always incontinent of stool. The MDS documented that the resident had no current pressure sores, is at risk for developing pressure ulcers, and had a history of pressure ulcers prior to this assessment. The MDS documented that skin and ulcer treatments included pressure reducing devices for the bed and chair.

Review of the Comprehensive Care Plan (CCP) for Pressure Ulcers dated 12/20/11 revealed there were no open areas at the time with planned interventions to "provide special equipment for pressure relief". Additional review of the CCP revealed a "Problem" dated 12/22/11 identifying that the resident was non-compliant with the use of pressure relieving devices with a goal for the resident to verbalize understanding with teaching and allow wound prevention and treatment. Planned interventions included plans to re-approach the resident with refusals.

Review of Therapy Notes and Nursing Observations and Progress Notes from 12/1/11 to 1/18/12 revealed no documented evidence that the resident refused a special mattress as assessed on the MDS.

Intermittent observations of the resident on 1/17/12 and 1/18/12 from 6:00 AM to 4:00 PM revealed the resident was bedbound and the mattress on the bariatric bed (bed designed for obese patients) was not a pressure relieving mattress.

Interview with Maintenance staff on 1/18/12 at approximately 11:00 AM revealed Resident #439's mattress was a standard mattress which came with the bed; a vinyl covered 6 inch (") thick foam mattress.

Interview with the Registered Nurse (RN) Head Nurse on 1/18/12 at approximately 8:30 AM revealed the resident did not have a pressure ulcer. Further interview with the RN Head Nurse on 1/18/12 at 11:30 AM revealed she did not believe the resident needed a pressure relieving mattress at this time since he did not have current skin breakdown.

Interview with the resident on 1/8/12 at approximately 4:00 PM revealed he had refused turning and positioning because it is difficult for him to stay on his side because of his breathing problems and tracheostomy. The resident stated he has never been offered and did not refuse a special pressure relieving mattress.

2. Resident #282 has diagnoses of diabetes mellitus and hypertension. Review of the Minimum Data Set (MDS) dated 11/30/11 revealed the resident has moderate cognitive impairment, is understood, and usually understands. Additional review of the MDS revealed the resident requires extensive staff assistance for toileting, personal hygiene and dressing, and limited staff assistance for transfer and ambulation.

Review of the Comprehensive Care Plan reviewed 12/7/11 revealed the resident has a problem with urinary incontinence with a planned intervention to apply barrier cream after each incontinent episode.

Observation on 1/18/12 at 6:30 AM revealed a certified nurse aide (CNA) was placing an incontinence brief on the resident who was standing next to the bedside and a white substance was observed on the resident's buttocks. Urine soaked incontinence pads were on the bed. The CNA finished putting on the brief and pulled up the resident's pants which were down around her ankles.

Interview with the CNA on 1/18/12 at 6:30 AM revealed she provided incontinence care because the resident was incontinent of urine. The CNA stated she put moisturizing cream and baby powder on the resident's buttocks because the resident did not have barrier cream in her bedside drawer.

Observation on 1/18/12 at 7:00 AM revealed tubes of barrier cream were located in the clean utility room on the unit.

3. Resident #3 has diagnoses of anoxic (lack of oxygen) brain damage and seizure disorder. Review of the Minimum Data Set (MDS) dated 11/8/11 revealed the resident is in a persistent vegetative state and is totally dependent on staff for all activities of daily living (ADLs).

Review of an Activities Quarterly Assessment dated 12/7/11 revealed the resident has severely impaired cognition with a plan for the resident's radio to be turned on daily when the resident is in her room.

Review of the Comprehensive Care Plan (CCP) dated 11/15/11 revealed that the resident relies on staff to turn her radio or tapes on. CCP approaches include a plan to turn the radio on for stimulation.

Intermittent observations on 1/13/12 at approximately 9:00 AM; 1/18/12 at 9:00 AM, 10:00 AM, 11:00 AM, 12:30 PM, and 3:00 PM; and on 1/19/12 at 9:30 AM, 10:30 AM, 11:00 AM, and 12:30 PM revealed the resident was in her room. A radio was located on the resident's night stand but the radio was not turned on. During the observations, the resident was lying in bed with no auditory stimuli.

Interview with the CNA assigned to the resident for 1/18/12 and 1/19/12, on 1/19/12 at approximately 1:00 PM, confirmed that the radio was not turned on.

Interview with the Activities Director on 1/19/12 at approximately 3:00 PM revealed that the resident responds favorably to music and that playing music in the resident's room is part of her comprehensive care plan. The Activities Director stated that daily music is important for sensory stimulation because the resident has impaired vision and is non-verbal.

415.11(c)(3)(ii)

F159 483.10(c)(2)-(5): FACILITY MANAGEMENT OF RESIDENT FUNDS

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: March 20, 2012

Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section.
The facility must deposit any resident's personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.)
The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund.
The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative.
The facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

Citation date: January 20, 2012

Based on record review and staff interview, the facility did not ensure that residents had ready and reasonable access to their personal funds. One (Erie County Home) of two facility locations had an issue involving the lack of access to residents' personal funds on evenings, weekends and holidays. Specifically, financial representatives of cognitively impaired residents were not able to access personal funds. This was a pattern of no actual harm with potential for minimal harm.

The findings are:

1. Interview with the Cashier at the Erie County Home on 1/19/12 at approximately 10:30 AM revealed residents' personal funds are managed through the cashier's office during the week and by the security office after 4:00 PM on weekdays, weekends, and holidays. The Cashier explained that alert and oriented residents have access to their personal funds both during the week as well as on evenings, weekends and holidays; from both the cashier and security. Financial representatives of residents who are not able to manage their accounts have access to the residents' personal accounts during the weekdays when the cashier office is open, but not when the cashier's office is closed, on evenings, weekends and holidays.

Interview with the Cashier on 1/19/12 at approximately 3:30 PM revealed there are at least ten financial representatives of confused residents at the Erie County Home who are not able to have access to residents' personal funds on evenings, weekends, and holidays.

Review of a facility policy and procedure (P&P) dated 8/11/11 entitled Cashier General Duties revealed petty cash funds are available at the security desk on evenings and weekends. The P&P did not document that petty cash is not available to financial representatives, acting on behalf of cognitively impaired residents, on evenings, weekends and holidays.

415.26(h)(5)(i)

K18 NFPA 101: CORRIDOR DOORS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3
Roller latches are prohibited by CMS regulations in all health care facilities.

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 12/10/10.

Based on observation and staff interview during a Life Safety Code survey, corridor doors were obstructed from closing. This affected three (Units C, E, F) of ten resident units and two (East Building Basement, Service Building) of five resident use buildings at the Erie County Home. This affected one (Fifth Floor) of two resident use floors at the Erie County Medical Center SNF. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Observation on the Second Floor in the West building on Unit C on 1/12/12 at approximately 8:51 AM and on 1/13/12 at approximately 8:13 AM revealed that the door to room #W238B was obstructed from closing by a plastic door chock (plastic wedge) that was wedged under the door.

2. Observation on the Second Floor of the South Building on Unit F on 1/12/12 at approximately 9:13 AM revealed a chair was stored in front of and obstructing the door to the Pantry, room #S219 from closing.

3. Observation on the First Floor in the South Building on Unit E on 1/12/12 at approximately 9:55 AM revealed that the door to Nurse's office, room #S102B was obstructed from closing by an L-shaped piece of metal that was wedged under the door. Interview with the Director of Supply Services at this time revealed that he was not sure where the L-shaped piece of metal had come from and that it should not be obstructing the door from closing.

Observation on the First Floor of the South Building on Unit E on 1/17/12 at approximately 12:52 PM revealed that the door to the Nurse's office, room #S102B was obstructed from closing by an L-shaped piece of metal that was wedged under the door.

4. Observation in the Basement in the East Building on 1/12/12 at approximately 11:30 AM and on 1/13/12 at approximately 9:12 AM revealed a chair was stored in front of and obstructing the door to the Employee's Lounge, room #G58B from closing.

5. Observation on the First Floor of the South Building on Unit E on 1/13/12 at approximately 8:22 AM revealed a mechanical lift was stored in front of and obstructing the door to resident room #124 from closing.

6. Observation on the First Floor of Service Building on 1/18/12 at approximately 9:11 AM revealed that the door to room #SA104 was obstructed from closing by a plastic door chock that was wedged under the door. Further observation at this time revealed that this was one of the doors to the Crossroads Cafe.

Erie County Medical Center

7. Observation on 1/12/12 at approximately 9:52 AM revealed the corridor door to rooms #575 and #576 on Fifth Floor Zone #1 corridor was obstructed from closing by a gray tote on the floor that was pushed up against the corridor door. The gray tote contained several packages of "Shampoo Caps". Further observation revealed the corridor door was obstructed by the same gray tote on 1/13/12 at 11:22 AM and again on 1/8/12 at approximately 9:30 AM.

8. Observation on 1/13/12 at approximately 11:20 AM revealed the corridor door to resident room #580 on Fifth Floor Zone #1 had a walker in front of the door obstructing it from closing.

9. Observation on 1/18/12 at approximately 9:38 AM revealed the Tub room #566 on the Fifth Floor Zone #1 was held open with a black piece of rubber folded in half and wedged under the door.

K38 NFPA 101: EXIT ACCESS

Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Citation date: January 20, 2012

Based on observation and staff interview conducted during a Life Safety Code survey, it was determined that the Erie County Home did not maintain exit pathways in an accessible condition. This affected 2 of 37 exit discharge paths at the Erie County Home. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Observation on 1/17/12 at approximately 1:58 PM of the exterior exit path for the First Floor West building's exit discharge door 46B, revealed that this portion of the means of egress traverses a section of lawn, approximately 65 feet in length, before reaching a hard paved surface. On this occasion parts of the surface of this exit pathway were under water, wet and soggy. Means of egress, including their exterior pathways must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This same exit path way was cited during the Standard Surveys completed on 1/29/10 and 12/10/10. Means of egress, including their exterior pathways must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

2. Observation on 1/17/12 at approximately 3:30 PM revealed that the Unit A patio was enclosed by a chain link fence and gate and that the gate was locked with a padlock.

Interview with the Administrator and Director of Support Services on 1/18/12 at approximately 9:43 AM confirmed that the Unit A patio was enclosed by a chain link fence and gate and that the gate was locked with a padlock year round.
The West exit discharge doors of the South Building's three floors (Unit E, Unit F, South Basement) discharge into this patio. These are required exits and, as such, their exit pathway must be clear and unobstructed, throughout the entire distance, to the public way in accordance with the NFPA (National Fire Protection Association) 101 Life Safety Code. The presence of a lock on this gate renders the required egress paths to be non-accessible to the public way.

In keeping with new guidance from the Centers for Medicare & Medicaid Services (CMS), a revised time limited waiver must be requested. Please include in your Plan of Correction, a request for a Time Limited waiver and include the following:

- Justification for the waiver.
- Timetable with milestones of major activities leading to correction.
- All interim life safety measures that will be undertaken.

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 1/29/10 AND 12/10/10.

Based on observation and staff interview during a Life Safety Code survey, hazardous area doors would not self-close and latch into their frame and hazardous areas walls were not designed to resist the passage of smoke. This affected two (Units A, J) of ten resident units and one (Service Building) of five resident use buildings at the Erie County Home. This affected one (Sixth Floor) of two resident use floors at the Erie County Medical Center SNF. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Observation on the Second Floor in the North Building on Unit J on 1/12/12 at approximately 9:18 AM revealed an approximate four inch long by one inch wide open, unsealed penetration and an approximate 10 inch long by two inch wide open, unsealed penetration were observed in two of the walls of the Clean Linen room, room #N211.

2. Observation on the Second Floor in the North Building on Unit J on 1/12/12 at approximately 9:25 AM revealed the door to Storage room #N224 did not self-close and latch into its frame. Further observation at this time revealed that the door to this room lacked a latching mechanism.

3. Observation in the West Building on Unit A on 1/12/12 at approximately 10:41 AM revealed an approximate 12 inch long by eight inch wide open, unsealed penetration in one of the walls of the Clean Utility room, room #W152.

4. Observation on the First Floor of the Service Building in the Kitchen on 1/12/12 at approximately 11:01 AM revealed that there was a greater than one quarter inch gap between the double doors that separated the Kitchen from the Dietary hallway when the doors were observed to be in a fully closed position. Further observation at this time revealed that the Dietary Hallway was located between the Kitchen and the elevator located near the North Building. Interview with the Director of Support Services at this time revealed that maintenance staff had previously adjusted these doors.

Observation in the Kitchen on 1/12/12 at approximately 11:04 AM revealed that there was a greater than one quarter inch gap between the double doors that separated the Kitchen from the Dining Room in the Service Building when the doors were observed to be in a fully closed position.

Observation in the Kitchen on 1/12/12 at approximately 11:09 AM revealed that there was a greater than one quarter inch gap between the double doors that separated the Kitchen from the Staff Cafeteria/Staff Dining room in the Service Building when the doors were observed to be in a fully closed position.

Erie County Medical Center

5. Observation on 1/12/12 at approximately 10:09 AM revealed the corridor doors to the Soiled Holding room labeled #633 and #633a on the Sixth Floor, did not self latch into their door frames. When door #633a was physically pulled closed, the door did latch. When door #633 was physically pulled closed the door did not latch closed.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 1/29/10 AND 12/10/10.

Based on observation and staff interview during a Life Safety Code survey, portable fire extinguishers were obstructed, lacked a monthly inspection and/or needed to be recharged. This affected three (Units A, B, H) of ten resident units and the Basement of one (Service Building) of five resident use buildings at the Erie County Home. This affected one (Fifth Floor) of two resident use floors at the Erie County Medical Center SNF. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Erie County Home

1. Observation on the First Floor of the North Building on Unit H on 1/12/12 at approximately 9:45 AM revealed that the portable fire extinguisher located near resident room #137 was missing the monthly inspection for 10/11. Further observation of the tag attached the portable fire extinguisher revealed that the extinguisher was put into service in 9/11.

2. Observation on the First Floor of the West Building on Unit B on 1/12/12 at approximately 10:33 AM of the tag attached to the portable fire extinguisher located near the resident dining room, room #W124 revealed the extinguisher was missing the monthly inspection for 10/11. Further observation at this time of the tag attached to the portable fire extinguisher revealed that the portable fire extinguisher was put into service in 9/11.

3. Observation on the First Floor of the West building on Unit A, on 1/12/12 at approximately 10:38 AM revealed that the gauge on a portable fire extinguisher located near the resident dining room, room #W145 read "recharge".

4. Observation on the First Floor of the West Building on Unit B on 1/12/12 at approximately 10:45 AM revealed that a soiled linen receptacle was stored in front of and obstructing the portable fire extinguisher located near resident room #117.

Observation on the First Floor of the West Building on Unit B on 1/13/12 at approximately 1:21 PM revealed a mechanical lift was stored in front of and obstructing the portable fire extinguisher located near resident room #117.

5. Observation in the Kitchen storage area located in the Service Building Basement on 1/12/12 at approximately 11:15 AM of the tag attached to the portable fire extinguisher located near the Receiver's office, room #G47E revealed that the extinguisher was missing the monthly inspection for 10/11. Further observation at this time of the tag attached to the portable fire extinguisher revealed that the extinguisher was put into service in 9/11.

Interview with the Director of Support Services on 1/19/12 at approximately 2:05 PM revealed that the monthly inspections for the portable fire extinguishers were done and recorded on the tag attached to each of the extinguishers and that this was the only place that the monthly inspections were documented.

ERIE COUNTY MEDICAL CENTER

6. Observation on 1/12/12 at approximately 9:12 AM revealed the fire extinguisher on the Fifth Floor Zone #4 corridor was obstructed from use by an approximate six foot high by four foot wide nourishment beverage cart. Further observation at this same time revealed the staff person responsible for this cart was stocking the Zone #4 Galley kitchen.

7. Observation on 1/12/12 at approximately 9:25 AM revealed the fire extinguisher on the Fifth Floor Zone #3 corridor was obstructed from use by an approximate six foot high by four foot wide nourishment beverage cart. Further observation at this same time revealed the staff person responsible for this cart was stocking the Zone #3 Galley kitchen.

K75 NFPA 101: WASTEBASKETS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 20, 2012

Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5

Citation date: January 20, 2012

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 12/10/10.

Based on observation during a Life Safety Code survey, soiled linen receptacles with a capacity greater than 32 gallons were stored in areas that were not protected as hazardous areas. This affected six (Units A, B, C, D, F, J) of ten resident units at the Erie County Home. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

Erie County Home

1. Observation on the First Floor of the West Building on Unit A on 1/13/12 at approximately 8:05 AM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #132.

Observation on the First Floor of the West Building on Unit A on 1/17/12 at approximately 8:06 AM and 12:46 PM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #132.

2. Observation on the First Floor of the West Building on Unit B on 1/13/12 at approximately 8:06 AM and on 1/17/12 at approximately 12:45 PM revealed a partially full, approximately 230 gallon soiled linen receptacle and a partially full, approximately 115 gallon soiled linen receptacle were stored in the corridor near resident room #119.

3. Observation on the Second Floor of the West Building on Unit D on 1/13/12 at approximately 8:12 AM revealed a partially full, approximately 115 gallon soiled linen receptacle was stored in the corridor near resident room #232.

Observation on the Second Floor of the West Building on Unit D on 1/13/12 at approximately 8:13 AM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #232.

4. Observation on the Second Floor of the West Building on Unit C on 1/13/12 at approximately 8:14 AM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #238.

5. Observation on the Second Floor of the West Building on Unit C on 1/13/12 at approximately 8:15 AM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #251.

6. Observation on the Second Floor of the South Building on Unit F on 1/13/12 at approximately 8:17 AM and 1:35 PM revealed a full, approximately 115 gallon soiled linen receptacle was stored in the corridor near resident room #225.

7. Observation on the Second Floor of the North Building on Unit J on 1/13/12 at approximately 8:43 AM revealed a partially full, approximately 230 gallon soiled linen receptacle was stored in the corridor near resident room #225.

8. Observations on the First Floor of the West Building on Unit A on 1/13/12 at approximately 12:50 PM revealed a partially full, approximately 230 gallon soiled linen receptacle and a partially full, approximately 115 gallon soiled linen receptacle were stored in the corridor near resident room #138.